Western Node Spread Call #2 Feb 5th, 2009

1. Understand when you are ready for spread ◦ Reliable design ◦ Support systems for sustainability ◦ NHS sustainability model 2. Identifying the scale, scope and social context of your spread plan ◦ Spread AIM ◦ What, Who and How 3. Introduce some planning tools

 The science of taking a local improvement (intervention, idea, process) and actively disseminating it across a system  There are many possible definitions for “a system” (e.g. a hospital, a group of hospitals, a region, a country) “New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

Adoption is a DOING thing! “BETTER IDEAS” Happens over time COMMUNICATED Thru a SOCIAL system Adapted from Rogers, 1995 In a concrete targeted ways (C) 2001, Sarah W. Fraser Diffusion of Innovation Theory

 Sustainability ◦ New process, thinking, attitudes and support systems for the change become the norm & improve with time  Spread ◦ Spread is the result of the "process of adoption" - success is dependent on the willingness of others to adopt the ideas.  Adapting ◦ Customizing the change to culture, need or environment for the purposes of adoption  Adopting ◦ A conscious decision to implement a change; each individual must decide

SpreadAdoption Push ideas out towards othersPull ideas to myself My agenda at the center of a larger organization My agenda at the sharp end of delivering care Use of organizational structure and hierarchy to communicate the change Use of social systems to communicate about change Focus on tools, techniques and processes Focus on relationships and facilitation NHS Institute for Innovation & Improvement Source: Fraser & Plesk, 2003

“New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

From Improvement to Spread Spreading a change to other locations Developing a change Implementing a change Testing a change ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations Robert Lloyd

“A few observations and much reasoning lead to error; many observations and a little reasoning lead to truth.” ( ) born on Jun 28 US "surgeon, biologist". "He invented, with C. Lindbergh, the perfusion pump called artificial heart, 1936; Nobelist, 1912."

B. Harries, Improvement Associates, Holding the Gains and Spread presentation SHN WN Teleconference 11/07/06  Replicate gains under a variety of conditions ◦ Test the changes under a wide range of conditions (robust design) ◦ Judgment samplings ◦ Planned groupings  Foolproof the new process/procedure ◦ Reduce likelihood of mistake/error ◦ Use short feedback loops ◦ Use technology where appropriate

B. Harries, Improvement Associates, Holding the Gains and Spread presentation SHN WN Teleconference 11/07/06  Seek and use input from others  Use multiple PDSA cycles to implement the change  Collect data over time when conditions are expected to change  Redesign support processes for new process  Address the social aspects of change

 Integrate into organization  Continue measuring  Rely on others  Provide communication and education  Recognize hard work

PROJECT TEAM WORKSHEET: Redesign of Support Processes for Implementation of Change Change Implemented: Date: Cycle No. Change Tested or Implemented Lead June July August September October November Policies Documentation Hiring Procedures Staff education/training Job descriptions Information Flow Equipment Purchases Spring Learning Session June 18-19, 2003 IHI BTS Collaborative Holding the gains

Ask:  How well are the new processes being used?  Is the outcome data holding at/near target or improving  Have the structures been put in place to support the new process?  Do new staff know and do the new process?  Is the new process fully implemented in the pilot area?

 Set realistic spread timelines  Understand specifics of external pressures  Develop and maintain regular communication with leaders  Regularly communicate progress and key lessons

How By When What To Whom

Set-up -Target population -Adopter audiences -Successful sites -Key partners -Initial spread strategy A Framework for Spread Social System -Key messengers -Communities -Technical support -Transition issues Communication Strategies (awareness & technical) Knowledge Management Measurement and Feedback Leadership -Topic is a key strategic initiative -Goals and incentives aligned -Executive sponsor assigned -Day-to-day managers identified Better Ideas - Develop the case -Describe the ideas Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety Jun:31 (6):

Infrastructure, Leadership and Measurement Better Ideas Information about the Innovation and “Transfer Materials” Target Population “To and Through a Social System” Communicated Modes Purpose Messengers Based on materials from IHI and Veteran’s Health Administration Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety Jun;31(6):

23  Develop a Spread AIM  Leadership  Set-up/ infrastructure  Communication  Social System  Measurement and Feedback

24  Spread What:  Target Level of Performance:  Spread to Whom:  Time frame: Developing a Spread Aim

25  Spread What: All measures in the SSI Bundle  Target Level of Performance: Zero Cases of SSI  Spread to Whom: All surgical populations in our 10 hospital system  Time Frame: By September 2010 Sample Spread Aim: Prevent Surgical Site Infections by Implementing the SSI Bundle

 We have an overall spread plan  Our spread activities are included in strategic and business plans of our organization  We have visible and active support from our senior leader to spread our changes  Roles and responsibilities for spread are clearly defined  Senior leader assures success, remove barriers, make case for change  Day to day leaders communicate, develop messengers, educate, make it easy for others to do the work

‣ An honest ‘warts and all’ account of their journey ‣ Clear improvement goals ‣ Measures and results ‣ The challenges the team can’t unblock without senior leadership input ‣ Evidence of learning and sharing – will you help the chief executive to spread ‣ To be asked for money – results first is a good tactic ! Improvement Team and Leader: In Perfect Harmony? Regina Shakespeare Department of Health, UK, Building Momentum for the Future: Taking the Next Step in Patient Safety, Improvement Team and Leader: In Perfect Harmony? Winnipeg April 1 st & 2 nd 2008

‣ The pride and determination of professionals to improve the care they give ‣ Results ‣ Stories of how improvement has benefited patients and carers – sometimes they don’t get out much! ‣ Results ‣ Linking the improvement goals and measures to the organisation’s stay in business goals Improvement Team and Leader: In Perfect Harmony? Regina Shakespeare Department of Health, UK, Building Momentum for the Future: Taking the Next Step in Patient Safety, Improvement Team and Leader: In Perfect Harmony? Winnipeg April 1 st & 2 nd 2008

‣ Game playing, such as - using the access to pursue other agendas between professions, departments or business units ‣ Having to referee the team conflicts! ‣ Keeping your work an organisational secret ‣ Disregard for the organisation’s corporate agenda Improvement Team and Leader: In Perfect Harmony? Regina Shakespeare Department of Health, UK, Building Momentum for the Future: Taking the Next Step in Patient Safety, Improvement Team and Leader: In Perfect Harmony? Winnipeg April 1 st & 2 nd 2008

30  Set-up/Infrastructure ◦ Establishing steering committees ◦ Orienting leadership groups ◦ Organizing data collection ◦ Developing materials ◦ Identifying successful sites  General Communication ◦ Wide spread dissemination of information about the initiative ◦ Sending out comparative data ◦ Holding meetings with a broad range of potential adopters

31  Identification of Early Adopters ◦ The push of general communication from Level 1 results in pulling adopters to the project ◦ The number and different categories of adopters identified are good measures for LEVEL 1 activities ◦ The key activity here is identification of the early adopters and a plan for how they will be integrated into the work

32  Strategies to Get Adopters to Action ◦ Organizing purposeful peer-to-peer interaction that integrate adopters identified in your LEVEL 2 activities  e.g. mentoring, visiting, meetings with specific invitation lists, and group discussions around materials on the website ◦ Champions for successful sites identified in Level 1 can help to provide the technical support needed although each early adopter should be able to add to the knowledge exchange

33 ‣Building Awareness ‣Moving adopters from decision to action ‣Supporting and mentoring adopters

34  Feedback loops for LEVEL 3 activities ◦ Collecting and reviewing data on the adoption of the key changes and the outcome measures ◦ The aim is to understand how LEVEL 3 activities might be refined to improve upon results and how this might be best communicated with adopters  Feedback and adjustments may be needed for: ◦ Communication plans ◦ Materials and information ◦ Support and mentorship ◦ Infrastructure issues ◦ Social system issues

‣ You DON’T have to know it all before you start ‣You learn as you go ‣Spend 20 % on the Plan and 80% on the DOING ‣supporting and adapting ‣Keep the work VISIBLE ‣ to Staff and Leaders

 New Generation of Ideas on Spread, Dec 8, 2008 Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad, IHI National Forum  Strategies for Spreading Improvements in Health Care, October 14, 2004 Marie W. Schall, Institute for Healthcare Improvement  Holding the Gains and Spread, July 11, 2006 Bruce Harries, Improvement Associates  The Seven ‘Spreadly’ Sins, October 18, 2006 Roger Resar, MD & Carol Haraden, PhD IHI  Sustainability and Spread, August 28, 2006 Diane Jacobsen, MPH, CPHQ, IHI National Director  Continuing the Conversation Holding the Gains and Spreading Good Ideas: From Local Improvement to System-wide Change October 4, 2007 Marie Schall, MA Institute for Healthcare Improvement

National Health Services (NHS) Modernization Agency Improvement - Sustainability and its relationship with spread and adoption. Hinchey Judge KA. Et al., Factors Contributing to Sustaining and Spreading learning Collaborative Improvements, Qualitative Research Study Findings by the Primary Care Development Corporation, Dec Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety Jun:31 (6): Paul Plsek, Spreading Good Ideas for Better Health Care - A Practical Toolkit Volume 2 - Veterans Health Administration 2000 Research Series. VHA, Paul E. Plsek, Charles M. Kilo From resistance to attraction: a different approach to change - Positively Influencing Physicians Physician Executive, Nov-Dec, Dr. Lynne Maher, Emerging themes for improvement and innovation, presentation QHN Fall Forum, November 21, Developing your initial spread plan, IHI Boston Spread Workshop Feb Barb Saunders, Spread of Improvement Efforts – Guideline for Fraser Health, March 10, 2005

 Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety Jun;31(6):  Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992  Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc  Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press,  Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October  Dixon, N. Common Knowledge. Boston: Harvard Business School Press,  Fraser S. Spreading good practice; how to prepare the ground, Health Management, June  Gladwell, M. The Tipping Point. Boston: Little, Brown and Company,  Kreitner, R. and Kinicki, A. Organizational Behavior (2 nd ed.) Homewood, Il:Irwin,1978.

 Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass  Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg  Myers, D.G. Social Psychology (3 rd ed.) New York: McGraw-Hill,  Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September,  Rogers E. Diffusion of Innovations. New York: The Free Press,  Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, References